Va Approved

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  • Topic: United States Code, Social Security number, Veteran
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  • Published : April 15, 2013
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OMB Approved No. 2900-0265 Respondent Burden: 30 minutes

EDUCATIONAL/VOCATIONAL COUNSELING APPLICATION
PRIVACY ACT INFORMATION: The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal Regulations 1.576 for routine uses identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education, and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. Giving us your SSN account information is mandatory. Applicants are required to provide their SSN under Title 38 USC 5101 (c) (1). The VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Any information provided by applicants, recipients, and others may be subject to verification through computer matching programs with other agencies. RESPONDENT BURDEN: We need this information to determine if the veteran and other beneficiaries are eligible for counseling services that VR&E services proivde. Title 38, United States Code, allows us to ask for this information. We estimate that you will need an average of 30 minutes to review the instructions, find the information, and complete this form. VA cannot conduct or sponsor a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page at www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form. INTERNET VERSION AVAILABLE -You may download this application form at www.va.gov/vaforms 1A. NAME OF APPLICANT (FIRST-MIDDLE-LAST)

PART I - APPLICANT INFORMATION
1B. SOCIAL SECURITY NUMBER OF APPLICANT

1C. VA FILE NUMBER (If known)

2A. SEX OF APPLICANT MALE FEMALE 3A. RELATIONSHIP OF APPLICANT TO VETERAN SELF SPOUSE SURVIVING SPOUSE STEPCHILD CHILD ADOPTED CHILD

2B. APPLICANT'S E-MAIL ADDRESS

2C. DATE OF BIRTH

3B. APPLICANT'S TELEPHONE NUMBER (Including Area Code) PRIMARY PHONE NUMBER (Where a message

can be left)

OTHER PHONE NUMBER

3C. MAILING ADDRESS OF APPLICANT (Number and street or rural route, city or P.O., State and ZIP Code)

(For VA Use Only)

VA DATE STAMP

4A. ARE YOU A CHILD, 14 YEARS OR OLDER, SPOUSE, OR SURVIVING SPOUSE WITH A DISABILITY SEEKING SPECIAL RESTORATIVE TRAINING? YES NO

4B. ARE YOU A CHILD, SPOUSE, OR SURVIVING SPOUSE WITH A DISABILITY SEEKING SPECIAL VOCATIONAL TRAINING? YES NO

5. HAVE YOU RECEIVED AN INFORMATION PAMPHLET EXPLAINING SURVIVORS' AND DEPENDENTS' EDUCATIONAL ASSISTANCE BENEFITS? YES NO

6A. NAME OF VETERAN OR INDIVIDUAL ON ACTIVE DUTY ON WHOSE ACCOUNT BENEFITS ARE CLAIMED (FIRST- MIDDLE -LAST) 6B. SOCIAL SECURITY NUMBER 7. DATE OF BIRTH 8. BRANCH OF SERVICE 6C. VA FILE NUMBER (If known) 9. SERVICE NUMBER

PART II - INFORMATION CONCERNING DISABLED OR DECEASED VETERAN OR INDIVIDUAL ON ACTIVE DUTY

10. DATE OF DEATH OR DATE LISTED AS MISSING IN ACTION OR P.O.W.

PART III - SPECIAL INFORMATION CONCERNING APPLICANT
11. IF YOU ARE THE SPOUSE OF A DISABLED VETERAN, IS A DIVORCE OR ANNULMENT PENDING? YES NO 12B. SURVIVING SPOUSE'S AGE AT TIME OF REMARRIAGE 12A. IF YOU ARE THE SURVIVING SPOUSE OF A DECEASED VETERAN, HAVE YOU REMARRIED SINCE HIS OR HER DEATH ? YES NO

13. HAVE YOU EVER APPLIED FOR ANY OF THE FOLLOWING VA BENEFITS? (Check applicable box(es)) A. B. C. D. E. F. VOCATIONAL REHABILITATION BENEFITS (Chapter 31)...
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